Audits/Evaluation
Complaints
Confidentiality
Operations
Policy/Procedures
100
Is your work audited, if so, how often?
Answer:Yes, cases are audited by manager and team lead. Cases are audited at least monthly for staff that is greater than 90 days employed and at least weekly for staff that are employed less than 90 days. Cases may be audited more often if needed.
100
Describe what you do if you receive a complaint.
Answer: Identify and confirm issue/complaint, submit member complaint form: Accessed through Etools>Log Complaint or Quality Issue
100
Explain ways in which confidentiality is maintained
Answer: We utilize Rightfax, secure email for transmittal of information; PHI is maintained in locked cabinets; Lock cumputer screen when leave your desk; Place PHI or important document in shred bin.
100
What are your hours of operations?
8am - 9pm eastern M-Friday 8am - 6pm Saturdays 12pm - 6pm Sundays Members cannot be called before 8am or after 9pm. However employees can opt to complete other work duties around these hours.
100
Where are you policy & procedures located?
Answer: Located on the Document Sharepoint site called (HSMM Policies) Link: http://uniteddocs.uhc.com/optumhealth/plppr/default.aspx Also, SPARK (Shared Policy and Research database) link: http://spark.uhc.com/frames/frameset.aspx?workspaceId=&requestUrl
200
How often are evaluations performed?
Answer: Evaluations are performed annually
200
How are complaints documented?
Answer: Through Nexus which is in EMS (Enterprise Management System)
200
Does OH have standards addressing Privacy and Confidentiality?
Answer: Yes. Before PHI can be provided to any person, such person shall, in all cases (including, but not limited to, telephone, in person, online and IVR communications), be consistently identified and authenticated. We are to follow Privacy policies & procedure found on the link provided: http://inside.optumhealth.com/Department/ComplianceLegal/PrivacySecurity/
200
Did you receive training on conflict of interest? What do you do if you recognize there may be a conflict of interest?
Answer: Yes, through ULEARN. -Notify your manager of the possible conflict of interest or OR the Ethics & Compliance Help Center @ https://secure.ethicspoint.com/domain/media/en/gui/13549/index.html"
200
How are calls handled after hours? How do you answer the telephone?
Answer: Calls ae returned within 1 business day (24hrs). Rightfax, and voicemail are available 24hrs/day. Always provide your name, credentials, & name of organization when answering phone.
300
What work is audited?
Answer: Phone calls, data entry, case documentation
300
How would you handle a complaint from a member that says his physician isn’t focused on his care?
Answer: Submit complaint in EMS’s (Enterprise Management System) Nexus system, choosing-“Provider or Facility (QOC)” tab Offer listing of other In Network Providers
300
Who do you report HIPAA violations/ privacy breach to?
Answer: To our Privacy Manager: Sandy Berry at 614-410-7369 or Samia Haddad, Chief Compliance Officer at 952-917-7219. or visit link: http://www.inside.optumhealth.com/Department/ComplianceLegal/ReportIssues/
300
Describe a possible conflict of interest.
Answer: Examples Working on a case in which you may know the person such as a family member, friend, neighbor, or coworker. Outside employment that affects your work at UHG, example A26 business with companies for which a family member works Having family members report to you. "
300
When do you know when a Policy & procedure has been updated?
Answer: Through the documents updates listed on the document sharepoint. Through the training newsletter via email.
400
How is your work audited when you work remotely?
Answer: All work is entered into the same electronic systems and applications that in office staff utilizes.
400
What is the name of the system where all member complaints are housed?
Answer: Enterprise Management System
400
How often do passwords change? When was your last privacy/ HIPAA training?
Answer: Every 90 days. Privacy/HIPAA training takes place annually via ULEARN E&I trainings.
400
" How does your organization ensure that UM decisions are not influenced by conflicts of interest?
-All staff participate in conflict of interest training (ULEARN). "
400
Describe an immediate threat situation? How do you handle an immediate threat situation?
Answer:Answer: Resources: http://etools.uhc.com/operations/nurse_911process.asp ; *Jobaid "Emergency Medical Services Contact process" http://etools.uhc.com/operations/nurse_nd_hcr.asp Answer: Example 1 : Caller is threatening Suicide: Keep caller on phone. Obtain name/ID/telephone #/ present location. Inform co-worker by telling them/IM that you need assistance r/t Suicide threat/ Get UBH over asap! Example 2: Call has a medical Emergency: Keep caller on phone. Ask if family member or someone at home to help or dial 911 from their local phone. If not, Keep caller on phone. Get a coworker to dial 911 from a cell ot managers desk phone. Dial 1-800-225-5288 First prompt -choose 5 Second prompt -choose 4 Say it's an Emergency. I need an ambulance to (address). I am calling from UHC on behalf of (member's name). When the operator asks for a billing number give: Calling card number: 858-166-9098 Pin Number: 6125
500
How do you receive feedback on your audits?
Answer: Monthly PBSNACs; call and case audit results are sent to each nurse individually via email
500
Who can file a complaint?
Answer: The member or any if his/her designees
500
How do you maintain confidentiality while working from home? How do you access internet from home? How do you transmit PHI/faxes of PHI?
Answer: Close the door when others are present. Computer is secure with locking device, Passwords are required to logon to. Remote access via VPN & RSA token is required to log onto server. Rightfax is used for PHI/transmittal of PHI.
500
How do you receive updates on regulatory requirements? Did you receive an orientation or training? How long was your orientation? What type of training do you receive ongoing?
Answer: Operation Directors receive updates forwards the information to managers who disseminate to staff by email, staff meeting or training. Yes; Approx 3 weeks of classroom training and 1-2 weeks with a preceptor. Regulatory trainings, system updates, P&P updates
500
What are the timeframes for making preservice determinations?
Answer: Urgent: 24hrs Non-Urgent: 15 calendar days Urgent concurrent: 24 hrs Non urgent concurrent: 72 hrs Retrospective: 30 calendar days
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